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					  Human Reproductive Disorder


                      Xulan
• Dept. of G & O, the First Affiliated Hospital
  of Shantou University Medical College
• Introduction of Infertility

※ Definition
• Fecund: the ability to reproduce, typically
  used in context of women to become
  pregnant.
• Infertility: the inability to conceive after
  two years or more of trying with
  unprotected intercourse for couples.
                      ( WHO, one year)
• Primary infertility: no previous pregnancies
  have occurred

• Secondary infertility: a prior pregnancy has
  occurred, but inability to conceive again for
  two or more years exposure to intercourse,
  no matter how the result of the pregnancy is.
• What are the chances of a fertile couple
  actively seeking pregnant in a single month
  or cycle? 10%-20%
• The accumulated pregnancy rate during
  two years
__chances of conceiving by 6 months: 75%
__chances of conceiving by 1 year:90%
__10%-15%of couples will require longer
  than one year to conceive.
Epidemiology and etiology of infertility

Causes                        Percentage
Female factors                30-50 %
Male factors                  30 %
Both male and
female factors                 20 %
unexplained factors             10 %
So, the initial evaluation should include both
  the partners.
※ Female Infertility

• Causes
1. Ovulatory dysfunction: 25%.
2. Tubal factors: 30%-50%
3. Pelvic factors
4. Cervical factors
5. Extra-genital tract factors
6. Others
      Female Factors Hypothalamus

                                    Pituitary
Follopian tube
                  Uterine
        ovary                        oocyte


                               Thyroid Adrenal
                 Cervix


         Extra-genital tract
Fig.1sperm
•   Ovulatory dysfunction

1. Hypothalamus: amenarrhea or mensrtual
   disorder
 -- Emotional depress
 -- Psychological trauma
 -- Environmental and Climate changes
2. Pituitary diseases:
 --Sheehan’s syndrome
 -- Pituitary tumor: Hyperprolactinemia,
 -- Empty sella syndrome
•   Ovary diseases:

1. Congenital dysformation:
    Turner’s syndrome(45,XO)
2. Polycystic syndrom(PCO)
3. Premature ovary failure(POF)
4. Ovary functional tumors
5. Insensitive to follicle stimulating
    hormones(FSH).
6. Other endocrinologic diseases: adrenal or
    thyroid dysfunction
● Pelvic Factors
 Tubal factors: tubal blokage, adhension and
  hydrosalpinx
1. Inflammations
 --Chlamydia
 --Gonorrhea
 --Tubercle bacillus and so on
2. Tubal dysformation
3. Pelvic adhension: endometriosis
4. Abdominal or pelvic surgery
5. Ectopic pregnancy
●Pelvic factors

 Pelvic Adhension
1.Inflammations:
 --Chlamydia, turbercle bacillum, gonorrhea,
  staphylococci and so on
2. Pelvic endometriosis
3. Pelvic surgery

●Reproductive system dysformation
-- Mayer-Rokitansky- Kuster-Hauser
 syndrome: no uterus and vagina
-- Uterus didelphys
-- Uterus bicornis
-- Uterus septus
-- Uterus unicornis
-- Rudimentary horn of uterus
-- others
Fig.3
Fig.5
Fig.8
Fig.9
Fig.10
Fig.11
Fig.12
Fig.13-1   Fig.13-2
• Cervical factors

-- Cervicitis :
 cervical erosion,
 cervical polyps,
 cervical hyperplasia
-- cervical stenosis
-- Cervical tumors: leiomyoma
-- Cervical cancer
●Extra-genital factors
-- Vulvo-vaginalitis
-- Vulvo-tumors
● Others
--Immunological factors:
 autoimmune response;
 auto-antibodies: AsAb, ACA, ANA, etc.
-- Genetic factors
-- Psychological factors:
-- Unexplained causes
• Evaluation and diagnosis

Initial evaluation
  The initial visit is the most important;
  the infertility is a problem of both of
  the couple; so, the male partner
  should be present at the beginning.
1. Taking history:
 -- marriage, menarche, menstruation
 -- duration of sexual relationships with or
   without birth control
 -- methods of birth control
 -- reproductive history of both partners (ie:
   children with previous
   partners/marriages)
2. Physical examination (PE)
 --General development
 -- Secondary sexual
  characteristics
3. Pelvic examination (PV)
 -- Bimanual exam
 -- Rectal-vaginal exam
4. Breast exam: masses and galactorrhea
5. Laboratory:
 -- hormonal testing:
 -- urinary LH surge test
 -- vaginal shedding cells test
 -- cervical mucus test
 -- post-coital sperm—cervical mucus test
6. Assisted imaging examination
 -- Ultrasound B continuous monitoring
 -- HSG
 -- Hysteroscopy
 -- Laparoscopy
• Treatment for female fertility

1. General therapy
-- Watchful waiting (provide more time for
  unassisted conception)

-- more frequent intercourse at mid-cycle

-- emotional support
2. Special therapy
 -- treatment of pelvic inflammation disease
  (PID)
 -- hydrotubation:
 -- selective salpingogram and recanalization:
  to make the obstructed site of the tube
  reopen under X-ray guidance
 -- hysteroscopy:removal of submucous
  leiomyoma, endometrial polyps, complete
  or incomplete uterus septum and separation
  of the cavity adhension.
 -- laparoscopy: adhension separation,
  ovarian tumors and leiomyoma removal
• Surgical approaches:
-- ovary cysts and tumors
-- severe pelvic adhension
-- Leiomyomas out of uterus wall
• Physical treatment for cervical erosion:
-- laser light
-- crpyotherapy
-- electrotherapy
• Anti-tuberculosis:
-- endometrial tuberculosis
-- salpingotuberculosis.
Medication therapy

• Ovulation induction
1. Clomiphene citrate(CC)
   M5 50-150mg qn×5
2. CC/HMG/HCG
  M5-9 CC 50-150mg
  M10-11 HMG 75IU qd
3. LHRH pulsive therapy
4. Bromocriptine---hyperprolactinemia
5. Metformin---PCO
6. HMG/HCG
  M3 HMG 75IU qd
    F 18-25mm, EN 8-10mm
    HCG10000IU qd
● Progesterone supplement
1. Post-ovulation, progesterone 10-20mg
    qd×7-10 days
2. HCG 2000IU-5000IUq3d82
3. Low dosage thyroid 20mg qd
 ● Assisted reproductive technology (not
   discussed here)
• Methods to monitor ovulation
-- Luteinizing Hormone monitoring:
    LH surge-- ovulation occurs after 34-36 hr,
    BBT--simple, cheap, biphasic pattern,
-- Mid-luteal serum progesterone: > 15.7nmol/mL,
   peak;
-- Premenstrual molimina: 95% presence,
-- Mucus change: thick and cellular, no crystalline
   fern,
-- Ultrasound monitoring: follicle size 21-23 mm,
                           fluid in the cul-de-sac.
※   Male infertility

• Causes
1. PRE-TESTICULAR CAUSES OF INFERTILITY
a. Hypothalamic disease
• Isolated gonadotropin deficiency
  (Kallmann's syndrome)
• Isolated LH deficiency ("Fertile eunuch")
• Isolated FSH deficiency Congenital
  hypogonadrotropic syndromes
b. Pituitary disease
• Pituitary insufficiency (tumors,
  infiltrative processes, operation,
  radiation)
• Hyperprolactinemia
• Hemochromatosis
• Exogenous hormones (estrogen-
  androgen excess, glucocorticoid excess,
  hyper and hypothyroidism).
2. TESTICULAR CAUSES OF INFERTILITY

a. Chromosomal abnormalities: Klinefelter's
   syndrome (XXY, karayotype), XX disorder
   (sex reversal syndrome), XYY syndrome
b. Noonan's syndrome (male Turner's
   syndrome)
c. Myotonic dystrophy- Bilateral anorchia
   (vanishing testes syndrome)
d. Sertoli-cell-only syndrome (germinal cell
   aplasia)
e. Gonadotoxins (drugs, radiation)
f. Orchitis
g. Trauma
h. Systemic disease (renal failure, hepatic
   disease, sickle cell disease)
i. Defective androgen synthesis or action
j. Cryptorchidism
k. Varicocele
3. POST-TESTICULAR CAUSES OF INFERTILITY
a. Disorders of sperm transport
● Congenital disorders
● Acquired disorders
● Functional disorders
b. Disorders of sperm motility or function
● Congenital defects of the sperm tail
● Maturation defects
● Immunologic disorders
● Infection
3. Sexual dysfunction
Fig.15
Fig.16
● Evaluation and diagnoses

1.History collection:
-- period of infertility without protected
  intercourse
-- present and previous marriage,
-- previous fertile history with partners,
-- frequency of intercourse,
-- method of birth control,
-- harmful habits: cigarette, alcohol, drug-
2. Physical examination

-- development of body: height and ratio of
  upper body sigment to low body sigment
-- Secondary sexual characteristics
  Inadequate body hair
  atypical genital hair distribution
  gynecomastia
-- Exam of reproductive system
  Size, masses (length, volume and mass) of
  scrotum
  Use orchidometer if possible
  Epididymis for scarring ,absence or
  induration
  Vas deferense for absence or nodules
  Varicocele
3. Laboratory test
-- Semen analysis
-- Karyotype (chromosome)
Normal Values for Semen Analysis


Volume                > 2.0 mL
Sperm concentration   > 20 million/mL
Motility              >50 %
A                     >25%
A+B                   >50%
morphology            >30 % normal
Data from WHO, 1992
Abnormal Values for Semen
Analysis

azoospermia—no sperm found
under microscope for at twice SA
at two weeks interval
oligospermia—sperm count less
than 20 million per 1mL
asthenospermia—the percentage
of normal morphology sperm less
than 30%
-- Endocrine test: <3%
  FSH,LH,T,PRL,E2,T3,T4,ACTH,TSH,GH
  hyperprolactinemia--MR
-- Blood biochemistry
  Liver enzymes and blood lipid
-- Immunologic antibody: AsAb
-- Special and sperm function tests
  Sperm-Cervical mucus interaction
  Sperm penetration assays
  Acrosome evaluation
  Hypoosmotis swelling
-- Bacteriologic test
  Bacterial culture for urine or prostate gland
   fluid
  and drug sensitive test
  Chlamydia trachomatis
  Mycoplasma hominus
  Ureaplasma urealyticulum
● Treatment
1. Surgical measures
 -- Varicocelectomy—varicocele
 -- Transurethral resection of ejaculatory
   duct
 -- Microsurgical epididymal sperm
  aspiration
 -- Ablation of pituitory Adenomas
 -- Prophylactic surgical measures—
  undescended testes
 2. Medical measures
 --Endocine therapy
  HMG,HCG,CC,Bromocriptine
 -- Treatment of infection
   antibiotics
 -- Empiric therapy—herbal treatment
3. Assisted reproductive techniques

				
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